Current Pain and Headache Reports (2019) 23: 48 https://doi.org/10.1007/s11916-019-0784-y

HOT TOPICS IN PAIN AND HEADACHE (N ROSEN, SECTION EDITOR)

Postoperative Management of Corneal Abrasions and Clinical Implications: a Comprehensive Review

Alan David Kaye1 & Jordan S. Renschler2 & Kelsey D. Cramer2 & Best O. Anyama3 & Easy C. Anyama4 & Julie A. Gayle5 & Cassandra M. Armstead-Williams5 & Chizoba N. Mosieri6 & J. Arthur Saus6 & Elyse M. Cornett6

Published online: 30 May 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract Purpose of Review Total patient care is of extreme importance during the administration of anesthesia. Proper care of the is necessary during all anesthetic administrations, especially during the administration of general anesthesia or monitored anesthesia care. By paying attention to details, the likelihood of an occurrence of eye injuries is reduced. Recent Findings Though perioperative eye injuries are rare during general anesthesia, they do account for 2–3% of claims against anesthesiologists. Ocular injuries may occur during general anesthesia even when tape has been utilized for eye closure. Corneal abrasions are the most common injuries that have been attributed to direct trauma to the eye, exposure keratopathy, or chemical injury. Using a hydrogel patch during general anesthesia is also associated with more frequent corneal injury than previously thought. Summary Prevention of anesthesia-related eye injuries assumes a high priority since the eye is one of the major sense organs of the body. The eye can be damaged during anesthesia for both non-ophthalmic and ophthalmic surgeries.

Keywords Corneal abrasions . . Perioperative eye injury . Ocular injury . Eye trauma

Introduction surface of the , the most anterior portion of the eye [1••, 2].Whilemostofthedamagetothewhiteareaof Corneal abrasions (CAs) are the most prevalent perioperative the eye is insignificant, even minor abrasions to the cornea ocular injuries. CA is defined as a defect in the epithelial are hastily filled by healthy cells to prevent refractive

This article is part of the Topical Collection on Hot Topics in Pain and Headache

* Elyse M. Cornett Chizoba N. Mosieri [email protected] [email protected] Alan David Kaye J. Arthur Saus [email protected] [email protected] Jordan S. Renschler 1 [email protected] Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA 70112, USA Kelsey D. Cramer 2 [email protected] LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA 70112, USA Best O. Anyama 3 Department of Anesthesiology, LSU Health Sciences Center, 1542 [email protected] Tulane Ave, New Orleans, LA 70112, USA Easy C. Anyama 4 University of Houston College of Optometry, 4901 Calhoun Rd, [email protected] Houston, TX 77204, USA Julie A. Gayle 5 Department of Anesthesiology, LSU Health Sciences Center, 1542 [email protected] Tulane Ave., Suite 659, New Orleans, LA 70112, USA Cassandra M. Armstead-Williams 6 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings [email protected] Highway, Shreveport, LA 71103, USA 48 Page 2 of 9 Curr Pain Headache Rep (2019) 23: 48 irregularities or vision-diminishing infection [3]. The cornea is Perioperative CAs have several different causes, many of a highly organized avascular arrangement of cells and proteins which can be prevented with intentional care. The majority of vital for vision function. It is responsible for barrier protection, perioperative CAs are assumed to come from lagophthalmos visible light refraction, and ultraviolet (UV) light filtration during general anesthesia. Lagophthalmos, the inability to ful- [1••, 2, 3, 4••, 5••]. The cornea is protected by pre-corneal tear ly close the from decreased contraction of the film made up of three layers: the outer lipid, deeper aqueous orbicularis oculi muscle, leads to corneal dryness and subse- layer, and innermost mucin layer [5••]. The lipid layer lubri- quent abrasion. It is important to ensure full eye closure to cates the aqueous layer which in turn oxygenates the corneal avoid exposure keratopathy. It is important for healthcare pro- epithelium [5••]. The underlying mucin layer creates a hydro- viders to be aware that the do not close in 59% of phobic coating that protects the corneal surface [5••]. The pre- patients because in 80–90% of perioperative CAs, no obvious corneal layer’s solidity is maintained through involuntary traumatic mechanism is identified [8, 11]. Furthermore, the blinking. Related to its location on the eye, the cornea is high- cornea is an avascular tissue that relies on constant bathing ly susceptible to injury. Although the origin of injury is often by tear film to stay oxygenated. This tear film is distributed not identified, mechanical trauma, such as being hit or around the cornea during blinking or eye closure. scratched in the eye, is a common factor that may lead to Lagophthalmos in general anesthesia allows the cornea to CA [1••, 2, 3, 4••, 5••]. Additionally, foreign bodies, contact dry out, which is a predisposing factor for corneal abrasion lens wear, corneal drying, and chemical or flash burns may [12]. damage corneal epithelial cells leading to the development of In addition to lagophthalmos, general anesthetics have oth- CA [2, 3]. The cornea is also highly innervated by the trigem- er effects on the eye that compound with dryness and increase inal nerve [3, 4••]. As a result, CAs can cause eye pain, blurred the patient’s risk for CA. Often the etiology of CA is hard to vision, headache, discomfort when blinking or opening the determine because of the interrelated effects of anesthesia. eye, excessive tearing, (light sensitivity), gritty Under general anesthesia, Bell’s phenomenon and firm stabil- feeling, and sensations. Small CAs can be ex- ity of the eye is absent. Bell’s phenomenon is an upward and tremely uncomfortable for patients, while deep CAs can cause outward movement of the eye when an attempt is made to corneal scarring, a defect that requires a transplant to restore close the , and is a normal defense reflex present in about vision [4••]. With regard to perioperative CAs, the majority 75% of the population. Bell’s phenomenon results in eleva- occur secondary to insufficient closing of the eyelids tion of the globes when blinking or when threatened (such as (lagophthalmos) [5••]. During normal sleeping conditions, when an attempt is made to touch an awake patient's cornea). the orbicularis muscle keeps the eyelid closed; however, gen- It becomes noticeable only when the orbicularis oculi muscle eral anesthesia limits tonic contraction [5••]. This manuscript becomes weak, and the intent of including this statement may will discuss risk factors, incidence of CA during anesthesia, be to postulate that weakness such as this may occur at the anesthesia effects on the eye, types of injury, prevention of onset of general anesthesia. This “Bell’s phenomenon” is pres- injury, diagnosis, chemical injury, ocular protection, treat- ent behind forcibly closed eyelids in most healthy people, and ment, pain relief, perioperative prevention of CA, and current should not be regarded as a pathognomonic sign. Due to clinical studies related to CA. Bell’s phenomenon, traumatic abrasions are generally located in the central or inferior cornea, but this “reflex” may be changed by administration of anesthesia. The cornea may re- main in the vulnerable space between the upper and lower Risk Factors eyelids instead of rotating upwards to be protected under the upper eyelid during eye closure. General anesthetic drugs CAs are the most common ocular injuries in the perioper- have direct effects on eye reflexes and tear production. The ative period for non-ocular surgeries [6]. Perioperative loss of the corneal blink reflex allows for prolonged irritation CAs can cause several undesired sequelae, including ocu- lar infection and vision loss. The overall incidence of cor- Table 1 Contributing Lagophthalmos neal abrasion during general anesthesia has been decreas- factors of CAs from general anesthesia Absent Bell’s Phenomenon ing with advancing medical knowledge. In 1977, a study Loss of corneal blink reflex (CN V found a CA incidence of 44% in general anesthesia prac- sensation, action from CN VII on tice before it was common practice to tape the eyes shut, orbicularis oculi) and eyes were left open and unprotected intraoperatively Decreased tear production [7]. More recent studies have found a range of CA inci- Decreased tear film stability dences during general anesthesia from 0.056% to 0.17% Increased venous outflow pressure – [3, 8 10]. Additionally, CAs in the perioperative period Elevated intra-ocular pressure affected a reported 19,903 people from 2009 to 2013 [2]. Curr Pain Headache Rep (2019) 23: 48 Page 3 of 9 48 of the cornea without a protective blink. Reflex loss combined are the agreed upon, while the upright factors are found in with decreased tear production and decreased stability of tear fewer studies and some have been contested [2]. film from anesthetic drugs increases risk for corneal abrasion There are several methods of preventing perioperative cor- during administration of general anesthesia. Additionally, neal injuries. These include manual closure of eyelids, simple when pressure is applied to the eye from a facemask or other taping of eyelids shut, use of eye ointment, paraffin gauze, equipment, venous outflow (which is normally at a very low bio-occlusive dressing, or suture tarsorrhaphy in some cases. pressure) is further impeded; this resulting decrease in outflow None of these is completely effective. Hence, extreme from an externally applied pressure increase easily leads to vigilance cannot be over-emphasized. of the cornea. The application of surface heating ma- terials such as the Bair-Hugger with its plastic drape placed over the patient’s face also increases the chances of drying out the eyes and as such, the major presenting complaint of such Types of Eye Injury patient will be “a painful eye or feeling of foreign object in the eye” in the postoperative care unit. Tracheal intubation with Presentation of Injury PEEP and head positioning in the OR also elevate intra-ocular pressure. The combined effects of corneal edema and in- Early detection and evaluation of CA in the perioperative set- creased IOP place the patient at higher risk for corneal abra- ting is important for successful treatment. Signs and symp- sion [3, 12–14]. See Table 1. toms of CA typically present in the early postoperative period. One-fifth of perioperative CAs are related to direct trauma These include complaints of eye pain, blurry vision, tearing, or chemical injury [11]. Further, if antiseptic or cleaning ma- redness, photophobia, and foreign body sensation [3]. terial are mistakenly spilled into the eyes, chemical injury can Additionally, patients in the postoperative recovery area may occur. The only non-toxic antiseptic skin preparation to the complain of pain with blinking because the eyelid rubs the cornea is povidone-iodine 10% aqueous solution. This, there- corneal abrasion with each blink [13]. See Table 3. fore, is the agent of choice in facial skin preparation. This is discussed in further detail in the “Types of Eye Injury” section. Reported traumas causing CAs include [6, 11, 14] Diagnosis

& Oxygen masks slipping up into patient’seyes Definitive diagnosis of corneal abrasion is confirmed with a & ID cards, watch straps, or other plastic wristbands/cards cobalt-filtered light and application of fluorescein. Fluorescein dangling into patient’s eyes during intubation or other pro- staining is used to reveal a defect in the corneal epithelium cedures and checks resulting from mechanical or chemical injury. Following ap- & Chemical spills plication of topical anesthetic (proparacaine 0.5%) into the & Halothane irritation of the eyes, especially when eyes are eye, the lower lid is retracted downward and a fluorescein strip covered in a paraffin ointment that increases potency of is touched to the bulbar conjunctiva. As the patient blinks, the anesthetic gas irritation to the cornea dye spreads and stains the exposed basement membrane & Surgical drapes or instruments going into patient’seyes which shows yellow-green when a corneal abrasion is present. & Patients rubbing their eyes in recovery, especially if they See Fig. 1. are wearing a finger pulse oximeter Ophthalmoscopes, slit lamps, and Wood’s lamps with a cobalt blue filter illuminate a corneal defect as yellow-green To decrease morbidity from CAs during general anesthesia, after fluorescein staining [1••]. A is helpful in deter- it is imperative to identify which patients are at risk, then mining the extent of a corneal abrasion. In the absence of a slit prevent injury or intervene as soon as possible. Current liter- lamp, use of a cobalt blue light with fluorescein helps deter- ature lists many risk factors for perioperative CA, which are mine the size and location of a corneal abrasion [13]. See included in Table 2 [3, 8, 10, 12–14]. Factors listed in italics Fig. 2.

Table 2 Risk factors for perioperative corneal abrasion Longer surgery duration Advanced patient age Use of general anesthesia drugs History of ophthalmic issues (exophthalmos, proptosis, dry eyes) Lateral position during surgery Oxygen use to/from PACU Surgery on a Monday Higher estimated blood loss Trendelenburg position Prone position 48 Page 4 of 9 Curr Pain Headache Rep (2019) 23: 48

Table 3 Presentation of perioperative CA

Signs Symptoms

Scleral injection and redness Eye pain Blinking Blurred vision tearing Photophobia Scratchy/foreign body sensation

Mechanical Injury

As previously mentioned, CA may result from direct trauma Fig. 2 Corneal abrasion after fluorescein stain under cobalt blue light to the cornea during induction of general anesthesia and intu- bation. With loss of the ciliary reflex following induction of general anesthesia, the unprotected eye is susceptible to injury a potential source of trauma to the cornea. Placing the probe by activities and equipment associated with mask ventilation on the non-dominant little or ring finger reduces the risk of and laryngoscopy including improperly sized masks, badges, iatrogenic corneal abrasion. Additionally, to reduce the risk of stethoscopes, watches, the anesthesia provider’sfingers,and mechanical trauma during occlusive tape removal at the end of the laryngoscope itself. surgery, it is recommended to remove tape from the upper to Patients undergoing surgery requiring the lateral or prone lower lid. Direct mechanical trauma may occur in the imme- position and patients having head or neck surgery are more diate postoperative period and in the recovery area by the susceptible to direct trauma to the eye and corneal abrasion. patient’s own fingers. Other objects that may cause a corneal Furthermore, patients undergoing lumbar laminectomy in the abrasion in the recovery phase are face mask or nasal cannula, prone position with the head turned to the side are particularly pulse oximeter probe, and a pillow. Restless activity and re- more susceptible to CA, typically in the lower positioned eye, covering in the lateral position also increase the risk of corneal as compared to all other neurosurgical procedures [15]. injury following anesthesia [13]. Pressure applied to the globe of the eye can reduce choroidal blood flow. The avascular nature of the cornea makes it more susceptible to decreased blood flow from the choroidal blood Chemical Injury supply to the peripheral cornea, with subsequent reduced ox- ygen delivery, resulting in corneal edema. Corneal abrasion Chemical injury may occur from surgical prep solutions ap- can occur in the presence of a dry environment, potentially plied to the unprotected eye. Direct chemical trauma to the resulting in desquamation of the eye’s epithelial layer. cornea can result from inadvertent spillage of sterilizing During or following emergence from general anesthesia, chemicals during surgical preparation. Antiseptic solutions patients often rub their eyes, making the pulse-oximeter probe with detergent readily penetrate the corneal epithelium, poten- tially causing damage to the underlying structures of the eye, leading to ischemia. De-epithelialization and edema of the cornea is caused by antiseptic solutions containing chlorhex- idine, cetrimide, alcohol, and aqueous povidone-iodine con- taining phenol. The only currently available antiseptic skin preparation which is non-toxic to the eye is preservative-free povidone-iodine in aqueous solution. Ophthalmic ointments are sometimes used in addition to taping the eyelids while under general anesthesia. Prevention of accidental corneal abrasions during the administration of general anesthesia is accomplished easily and effectively by simply placing a piece of tape over the completely closed eyelids. Ointments containing preservatives, methylparaben and chlorobutanol, may cause chemical injury. If ointment is used, it should be preservative-free. Irritating properties of the anesthetic gases, particularly those administered by face mask, and preservative-containing eye ointments may cause chemical Fig. 1 Corneal abrasion after fluorescein stain injury [13, 15]. Curr Pain Headache Rep (2019) 23: 48 Page 5 of 9 48

Perioperative Prevention of Corneal Abrasion end of the procedure is best accomplished by peeling the dress- ing down from the top of the eye to the bottom, thereby keep- Prevention of the occurrence of CAs is possible, and tape ing the eyelid completely closed until the Tegaderm™ Film is application over the closed eyelids is the best method for de- completely removed from the face. creasing the occurrence of CA’s. Accidental scratching of the exposed cornea by the hands or fingernails of the anesthetist during laryngoscopy and intubation or pressure by instru- ’ Detection of Corneal Abrasion ments or surgeon s hands have been reported as causes of in the Postoperative Period perioperative eye trauma [16]. A 2013 study of techniques for corneal protection during non-ocular surgery found that The occurrence of a corneal injury during the time of anesthe- the simple application of tape over the closed eyelids was sia is generally detected initially by the patient’s tearing from found to provide equal or superior protection to other inter- the injured eye, miosis, report of a sensation of the presence of ventions and had fewer side effects when compared to other a foreign body, and/or pain in the affected eye. These symp- methods of corneal protection such as petroleum gel applica- toms are often accompanied by photophobia. Frequently, this tion [15]. Simply closing the eyelids and taping them reduces will be noted in the post-anesthesia recovery room but may the chance of unintended corneal or scleral contact with a not be noticed until after the effects of opioid and other seda- foreign object; the application of lubricants does not generally tive agents have resolved in the postoperative period. Eye reduce risk of corneal or scleral damage during most surgical damage may also occur during the immediate postoperative procedures. It must be emphasized that if an eyelid partially period in the recovery room by eye contact by the oxygen face opens beneath any occlusive dressing or eyelid tape, this may mask, contact with bedclothes, or by the patient’sfingers[16]. still allow the eye to be injured from contact with the adhesive Confirmation of the injury is made by application of a moist- layer of the tape itself [16]. As mentioned previously, it is ened fluorescein strip to the surface of the eye. Using cobalt important to be certain the eyelid is completely closed prior blue illumination or a Wood’s lamp, areas of CA exhibit a to the application of the tape or adhesive dressing. Even the distinctly yellow-green stain when examined in this manner tape which is used for this task should be considered, since (see Fig. 2.). If this stain is noted to be in the inferior third of some tape may be more permeable to fluids (which may cause the eye and is crescent-shaped, this is an indication that the a chemical abrasion) than other tape products. likely cause was incomplete eyelid closure during the proce- In a study of common tapes used in the Operating Room dure. The appearance of this fluorescein stain from desiccation and permeability of the tape to a colored chlorhexidine prep due to incomplete eyelid closure is distinctly different from solution, the researchers discovered that while many tapes the appearance from abrasions caused by a foreign body pres- allowed the chlorhexidine solution to permeate through the ent in the eye or from eye contact with an irritating chemical. tape, 3M Durapore, 3M Tegaderm Film, and Hy-Tape did not allow the fluid to permeate through the tape [17]. Application of petroleum gel lubricant has been used in at- tempts to protect the eye and apply additional lubrication, but Ocular Treatment for Infection Prevention it is flammable and certainly should be avoided when open and Pain Relief oxygen and electrocautery are used around the face [15]. In summary, the best prevention and avoidance of perioper- Treatment of perioperative CAs should aim to prevent infec- ative eye injuries remains summed up in one word: vigilance. tion and control pain without reducing the rate of corneal Each person who is responsible for providing anesthesia to the healing [1••, 12]. Symptomatic care is the goal of treatment. patient should pay attention to activities which have the poten- Potential complications of CA include bacterial , cor- tial to cause eye injuries. Potential eye injuries can be neal ulcers, and recurrent erosion syndrome, which can prog- prevented by carefully closing the eyelids immediately follow- ress to and subsequent blindness [1••, 12, 19]. To ing anesthesia induction and loss of the reflex blink response to prevent infection, topical ointment should be ap- lightly stroking the eyelashes, then applying a piece of tape or plied for all cases of corneal abrasion. For uncomplicated similar adhesive dressing over the closed lids. When there is abrasions, erythromycin 0.5% ophthalmic ointment applied concern that liquids will be used around the eye during the four times a day for 48 h is the first choice of treatment [1••, surgical procedure, and a simple piece of tape may not provide 3, 12]. Other antibacterial options include polymyxin adequate protection, a small 6 cm × 7 cm Tegaderm™ Film B/trimethoprim (Poly-trim) ophthalmic solution, and may be carefully applied over each closed eyelid and surround- sulfacetamide 10% ophthalmic ointment or solution [1••]. ing skin of the face to provide a better and more “water-tight” with activity against Gram-negative organisms seal for the duration of the surgical procedure [18••]. If this is should be considered in patients who wear contacts due to applied for eye protection during the surgery, removal at the potential for pseudomonal infections [1••, 12]. 48 Page 6 of 9 Curr Pain Headache Rep (2019) 23: 48

Treatment should avoid neomycin because of its increased once thought [12, 21]. A recent study examining two ran- risk of contact hypersensitivity. Also contraindicated for top- domized, double-blind controlled trials suggests that when ical treatment are formulations with steroids, because they used appropriately at dilute concentrations, topical anes- increase susceptibility of infection and may delay healing thetics can be extremely efficacious at managing pain with [1••, 12]. Antibiotics can be applied by solution or ointment. no adverse events [25]. While more evidence is required, Ointment may act as a lubricant, providing more pain relief solutions of 0.05% proparacaine or 1% tetracaine have been than solution and is retained in the eye longer, acting as a film demonstrated to improve pain symptoms without impairing to prevent tear evaporation [1••, 12]. healing [12, 26, 27•, 28•]. Small abrasions are classified as those that occupy less than Another review by Wakai et al. further examined the same one-fourth of the cornea. These small abrasions often heal randomized controlled trials to compare topical NSAIDs (1% overnight, and oral NSAIDs may be used to manage pain indomethacin, 0.03% flurbiprofen, 0.5% , 0.1% in- while the abrasions heal. The use of topical NSAIDs or domethacin, 0.1% diclofenac) to other traditional methods topical anesthetics in addition to oral NSAIDs is currently including artificial , patching, antibiotic eye drops, and debated. Larger abrasions may require 48 h to heal, and in placebo drops. This review determined that it was unclear if addition to NSAIDs, parasympatholytic drops, also known topical NSAIDs reduced pain relative to the control, but as cycloplegics, and patching may be considered during NSAIDs may reduce patients’ use of oral painkillers [29]. If healing. Despite recommendations, there is a lack of consen- topical NSAIDs are used, they should be used for only un- sus for how to best manage pain following corneal abrasion. complicated abrasions and for no longer than 2 days due to Cycloplegics prevent the eye from responding to light, thus corneal toxicity with prolonged use [1••, 12, 20, 29]. Topical possibly reducing movement-induced pain while the cornea NSAIDs are also more expensive than topical anesthetics, and heals. Short-acting cycloplegics include one drop of this should be discussed with patients before being prescribed. (0.5 to 1%) twice daily or one drop homatropine Both studies determined further research needs to be done to (2.5 to 5%) once daily. Even short-acting cycloplegics may conclude the best recommendations for managing pain after cause side effects for up to 36 h, including causing glare and corneal abrasion [20, 29]. lack of accommodation, resulting in difficulty reading and To effectively treat perioperative CA and manage pain, driving. These side effects may make the use of cycloplegics physicians should prescribe a topical antibiotic such as eryth- unrealistic for pain control of small abrasions, and there is a romycin 0.5% ophthalmic solution, paired with oral NSAIDs. lack of strong evidence supporting efficacy of cycloplegics at Further pain management may include a low-dose topical an- relieving pain [20, 21]. esthetic (0.05% proparacaine or 1% tetracaine) or a topical Patching acts as a barrier to mechanical and chemical inju- NSAID (1% indomethacin, 0.03% flurbiprofen, 0.5% ry, as well as infection. While patching was once recommend- ketorolac, 0.1% indomethacin, 0.1% diclofenac) at the discre- ed to allow for corneal healing, recent studies concluded that tion of the physician. Topical cycloplegic should only be con- patching neither reduces pain nor aids in healing of CA and sidered in management of large CA, and patching is no longer may actually delay healing [1••, 12, 22, 23]. Patching also recommended. See Table 4. inhibits depth perception and may not be well tolerated by patients. Despite patching’s low efficacy at relieving pain and healing time, it may be considered to reduce the incidence of CA perioperatively [22]. Recent Clinical Findings The use of topical anesthetics for management of CA is controversial. A recent review examined the results of ten A 2012 case report discussed a patient diagnosed with periop- randomized controlled trials to determine the outcomes of erative corneal abrasion in the right eye shortly after a laparo- patients receiving topical analgesics. The review concluded scopic inguinal hernia repair [30]. The authors then reviewed that topical NSAIDs reduced pain symptoms, while topical cycloplegics and topical anesthetics did not significantly re- duce pain [20]. Patients using topical NSAIDs also reported Table 4 Types of CA infections and corresponding treatments greater pain relief [24]. Additionally, topical anesthetic, such Pain relief agent Indication as a 0.5% proparacaine solution, were once thought to lead to delayed wound healing. Overuse of topical anesthetics can NSAIDs Small and large CA potentially have serious side effects due to lack of pain per- Topical NSAIDs Consider for small CA ception and can even evolve to blindness. While these con- Topical anesthetics Consider for small CA cerns for safety confirm the need for close monitoring of Topical cycloplegics Large CA treatment, recent literature suggest topical anesthetics may Patching No longer recommended be more effective and cause less healing impairment than Curr Pain Headache Rep (2019) 23: 48 Page 7 of 9 48 consults placed by anesthesia within the past Another 2015 literature review evaluated randomized 6 months and discovered six cases of consults placed for peri- control trial studies using topical anesthetics for less than operative corneal abrasion when compared to the prior 6 months, 72hinadultpatients[32]. The review was unable to find when there were no consults placed. The anesthesia department evidence of superiority of topical anesthetics over placebo of the authors’ facility held an interdepartmental meeting for corneal abrasion treatment. Currently, topical anesthet- attended by all departments and collaborated on strategies to ic treatment for corneal abrasion is not supported by evi- reduce the incidence of perioperative abrasions. Strategies in- dence [32]. cluded a formal incidence-tracking mechanism, frequent intra- A prospective, randomized double-blinded study in 2016 operative reassessments to make sure the eye is closed, and compared the efficacy of eye-protection methods used in 72 taping the eyelid horizontally rather than vertically [30]. patients (i.e., 144 eyes) [33]. These patients were randomly A retrospective review study in 2014 reviewed patients divided into four groups: control group (manual eye closure), diagnosed with corneal abrasions over a 2-year period in in- tape group (bandage attached over the eyelid), ointment group traoperative and postoperative patients [3]. Corneal abrasion (eye ointment instilled in eye prior to manual eye closure), and cases were compared to unmatched controls to determine risk ointment-tape group; however, the authors found no signifi- factors, treatment time, and most commonly prescribed treat- cant difference in the indigence of corneal abrasions amongst ments for corneal abrasions. A total of 78,542 surgical cases the groups (23.5%, 16.7%, 21.6%, 16.2%, respectively; P = over a 2-year period were reviewed. Of these cases, corneal 0.826) [33]. abrasions occurred in 0.11% (n = eight six). The most com- A literature review evaluating randomized controlled trials mon type of surgery that occurred in the corneal abrasion in 2017 addressed the efficacy and safety of three classes of group was urological, 31% versus 11% in control cases, with topical eye medications used for analgesia in corneal abra- robotic prostatectomy being the most common type of uro- sions: topical non-steroidal anti-inflammatory drugs logical surgery (48%). Duration length of surgery was longer (NSAIDs) (n = 6), topical anesthetics (n = 3), and topical for corneal abrasion group, 3.85 h vs 1.7. Most of the corneal cycloplegics (n =1)[20]. The authors concluded that evidence abrasion group received general anesthesia when compared to was there to support the use of topical NSAIDs as the standard control (95% versus 47%, respectively). In the corneal abra- for the management of corneal abrasions, and they were sion group, 6% were in prone position and 25% were in deemed as a safe option for to use for wound healing. Trendelenburg position. More corneal abrasions occurred in Further studies were needed to encourage the use of topical the main PACU versus ambulatory PACU or other recovery anesthetics and topical cycloplegics [20]. sites (69% versus 24%). All the aforementioned percentages were statistically significant [3]. Another prospective, randomized double-blinded study conducted in 2014 evaluated the efficacy of hydro-gel eye Conclusion patch in preventing corneal abrasions [31]. Seventy-six pa- tients were randomly divided into two groups, hydrogel eye CAs are the most commonly occurring ocular injury in the patch group, and adhesive tape group (control group). The perioperative period. Most often, the abrasions heal in 24 to hydrogel patch group had 12 eyes (15.8%) that showed cor- 48 h, but some cases progress to serious eye infections leading neal injury with fluorescein under a slit lamp immediately to permanent vision loss. This review looks at the etiology and after surgery, while the control group had 30 eyes (39.5%) treatment options for CA, focusing on the role of the anesthe- (P < 0.01). The authors concluded that hydrogel eye patch is tist in the postoperative management of CA. superior to adhesive tape in preventing corneal abrasions [31]. The key to preventing CAs in the OR is to first identify An observational, single-institution study in 2015 assessed patients at risk (old age, long surgery, preexisting ocular con- the effectiveness of a pre-established anesthesiology-based dition; see table for complete list). All patients should have protocol for the management of corneal abrasions [10]. A total their eyes closed by tape or Tegaderm immediately after intu- of 91,064 surgical cases over a 5-year period were reviewed. bation to minimize corneal drying from lagophthalmos. This The incidence of corneal abrasion was 0.13% (n = 118) during tape should be left in place until the end of the procedure and this period. The anesthesia department was able to manage should be removed from the top to the bottom, so the eye stays 93.22% (n = 110) of perioperative corneal abrasions, while fully closed. Every provider giving care to the patient should ophthalmology was consulted for the remaining eight. The be cognizant of the drugs and materials in their possession to study found that older age and longer duration time of surgery reduce risk of trauma to the patient’s eyes. In the PACU, were significant risk factors of corneal abrasion. The authors bedding, tubing, and masks should all be secured and away concluded that minor corneal abrasions can be managed safely from the patient’s eyes. Pulse oximetry probes should be and effectively using an anesthesiology-based algorithm ap- moved to the non-dominant small finger to prevent injury proach [10]. from the patient’s own fingers. 48 Page 8 of 9 Curr Pain Headache Rep (2019) 23: 48

CAs are normally found in the PACU when the patient 7. Batra YK, Bali IM. Corneal abrasions during general anesthesia. – complains of tearing, foreign body sensation, blurred vi- Anesth Analg. 1977;56(3):363 365. 8. Roth S, Thisted RA, Erickson JP, Black S, Schreider BD. Eye sion, photophobia, and eye pain. These complaints should injuries after nonocular surgery: a study of 60,965 anesthetics from lead to immediate fluorescein examination and evaluation 1988 to 1992. Anesthesiology. 1996;85(5):1020–7. for CA. After a corneal abrasion is identified, there are two 9. Cucchiara RF, Black S. Corneal abrasion during anesthesia and – main arms of management—pain control and infection pre- surgery. Anesthesiology. 1988;69(6):978 9. 10. Lichter JR, Marr LB, Schilling DE, Hudson ME, Boretsky RH, vention. For most uncomplicated patients, topical ophthal- Barad RF, et al. A Department-of-Anesthesiology-based manage- mic erythromycin ointment is the first antibiotic choice and ment protocol for perioperative corneal abrasions. Clin oral NSAID therapy is the first pain management choice. Ophthalmol. 2015;9:1689–95. Topical NSAIDs or topical anesthetics may also be pre- 11. Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries asso- ciated with anesthesia. A closed claims analysis. Anesthesiology. scribed at the discretion of the physician with close moni- 1992;76(2):204–8. toring. Selecting the best pharmacotherapy for patients in- 12. Malafa MM, Coleman JE, Bowman RW, Rohrich RJ. Perioperative volves balancing infection prevention and pain control with corneal abrasion: updated guidelines for prevention and manage- – delayed corneal healing and the inconvenience of some ment. Plast Reconstr Surg. 2016;137(5):790e 8e. 13. Moos DD, Lind DM. Detection and treatment of perioperative cor- therapies. Provider awareness and vigilance are the keys neal abrasions. J Perianesthesia Nurs. 2006;21(5):332–8. to reducing risk factors and promptly detecting CA in the 14. White E, Crosse MM. The aetiology and prevention of peri- perioperative period. operative corneal abrasions. Anaesthesia. 1998;53:157–61. 15. Grixti A, Sadri M, Watts MT. Corneal protection during general anesthesia for nonocular surgery. Ocul Surf. 2013;11(2):109–18. Compliance with Ethical Standards 16. Snow JC, Kripke BJ, Norton ML, Chandra P, Woodcome HA. Corneal injuries during general anesthesia. Anesth Analg. Conflict of Interest Jordan S. Renschler, Kelsey D. Cramer, Best O. 1975;54(4):465–7. Anyama, Easy C. Anyama, Julie A. Gayle, Cassandra M. Armstead- 17. Reimer C. Eye taping during anesthesia and chlorhexidine expo- Williams, Chizoba N. Mosieri, J. Arthur Saus, and Elyse M. Cornett sure. Can J Anesth Can d’anesthésie. 2017;64(11):1159–60. declare no conflict of interest. Alan D. Kaye serves on the Speakers 18.•• Prakash S. Perioperative eye protection under general anesthesia. J Bureau of Depomed and Merck. Anaesthesiol Clin Pharmacol. 2013;29(1):138–9. This letter to the editor is important because Prakesh addresses several items Human and Animal Rights and Informed Consent This article does not related to eye protection that should be noted by physicians. contain any studies with human or animal subjects performed by any of 19. Mendel E, et al. Revisiting postoperative vision loss following non- the authors. ocular surgery: a short review of etiology and legal considerations. Front Surg. 2017;4:34. 20. Thiel B, Sarau A, Ng D. Efficacy of topical analgesics in pain control for corneal abrasions: a systematic review. Cureus. 2017;9(3):e1121. References 21. Puls HA, Cabrera D, Murad MH, Erwin PJ, Bellolio MF. Safety and effectiveness of topical anesthetics in corneal abrasions: systematic – Papers of particular interest, published recently, have been review and meta-analysis. J Emerg Med. 2015;49(5):816 24. 22. Lim CH, Turner A, Lim BX. Patching for corneal abrasion. highlighted as: Cochrane Database Syst Rev. 2016;7:CD004764. • Of importance 23. Flynn CA, D’Amico F, Smith G. Should we patch corneal abra- •• Of major importance sions? A meta-analysis. J Fam Pract. 1998;47(4):264–70. 24. Wilson SA, Last A. Management of corneal abrasions. Am. Fam. Physician. 2004;70(1):123–8. 1.•• Wipperman JL, Dorsch JN. Evaluation and management of corneal 25. Swaminathan A, Otterness K, Milne K, Rezaie S. The safety of abrasions. Am Fam Physician. 2013;87(2):114–20. This article is topical anesthetics in the treatment of corneal abrasions: a review. important because it is a comprehensive review with pertinent J Emerg Med. 2015;49(5):810–5. information related to this topic. 26. Ball IM, Seabrook J, Desai N, Allen L, Anderson S. Dilute 2. Morris A, Bonanno L, Bennett M. Effectiveness of corneal abrasion proparacaine for the management of acute corneal injuries in the prevention interventions for adults undergoing general anesthesia emergency department. CJEM. 2010;12(5):389–96. for more than one hour: a systematic review protocol, JBI database. 27.• Waldman N, Winrow B, Densie I, Gray A, McMaster S, Giddings – Syst Rev Implement reports. 2018;16(9):1785 90. G, et al. An observational study to determine whether routinely 3. Segal KL, et al. Evaluation and treatment of perioperative corneal sending patients home with a 24-hour supply of topical tetracaine abrasions. J Ophthalmol. 2014;2014:901901. from the emergency department for simple corneal abrasion pain is 4.•• Wilson SA, Last A. Management of corneal abrasions. Am Fam potentially safe. Ann Emerg Med. 2018;71(6):767–78. This article Physician. 2004;70(1):123–8. This article is of importance be- is of importance because it is a timely research study regarding cause it is a reliable and comprehensive review of the topic. the topic in this manuscript. 5.•• Palte HD. Revisiting Perioperative Corneal Abrasion. ASA 29.• Waldman N, Densie IK, Herbison P. Topical tetracaine used for 24 Monitor 2018;82:22–25. http://monitor.pubs.asahq.org/article. hours is safe and rated highly effective by patients for the treatment of aspx?articleid=2670625. This article is of importance because pain caused by corneal abrasions: a double-blind, randomized clinical it is a recent review of corneal abrasions. trial. Acad Emerg Med. 2014;21(4):374–82. Important study show- 6. Barash PG, Cullen BF, Stoelting RK, editors. Clinical anesthesiol- ing tetracaine efficacy for corneal abrasion in a double blind ogy. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. study. Curr Pain Headache Rep (2019) 23: 48 Page 9 of 9 48

29. Wakai A, Lawrenson JG, Lawrenson AL, Wang Y, Brown MD, 32. Puls HA, Cabrera D, Murad MH, Erwin PJ, Bellolio MF. Safety and Quirke M, et al. Topical non-steroidal anti-inflammatory drugs for effectiveness of topical anesthetics in corneal abrasions: systematic analgesia in traumatic corneal abrasions. Cochrane Database Syst review and meta-analysis. J Emerg Med. 2015;49(5):816–24. Rev. 2017;5:CD009781. 33. Lee S-J, Kim SI, Chung JK, Koh EH, Cho A, Cho HB, et al. 30. Weed M, Syed N. Perioperative Corneal Abrasions: Systems-based Comparison of eye protection methods for corneal abrasion during review and analysis. 2012. Available from: http://EyeRounds.org/ general anesthesia. Anesth Pain Med. 2016;11:99–103. cases/152-perioperative-corneal-abrasions.htm. 31. Wan T, Wang Y, Jin X-M. Corneal injury and its protection using Publisher’sNote Springer Nature remains neutral with regard to hydro-gel patch during general anesthesia. Int J Ophthalmol. jurisdictional claims in published maps and institutional affiliations. 2014;7(6):964–7.